Victoria Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Victoria Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 21, 2021

  Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) was free from accident hazards. * Resident 1 had a fall while being transferred on 9/14/20. The facility failed to investigate the fall and there were no interventions put in place to prevent Resident 1 from further falls. The PT evaluated Resident 1 on 9/16/20, and recommended two-person assistance for transfers. This recommendation was not communicated to the nursing staff and was not implemented. […]

• No harm, potential for more than minimal, patternF812Aug 14, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the microwave utilized to warm up the residents' food was in a sanitary condition. * The facility failed to ensure the heavy-duty blender used for puree preparation, two clear plastic pitchers and one stainless steel spatula with black handle were air dried prior to storage. * The facility failed to ensure the heavy-duty blender, kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting board was maintained in sanitary condition and had smooth, cleanable surface. […]

• No harm, potential for more than minimal, patternF881Aug 14, 2026

  Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection. * The facility failed to assess the McGeer's criteria for three admitted residents (Residents 4, 7, and 92) who were prescribed antibiotics in July and August 2026. This failure had the potential for inaccurately identifying true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antimicrobials.Findings: Review of the facility's P&P titled Antibiotic Stewardship revised on 1/2022 showed it is the policy of the facility to implement an Antibiotic Stewardship Program (ASP) that… […]

• No harm, potential for more than minimal, patternF812Jul 23, 2025

  Based on observation and interview, the facility failed to ensure sanitary conditions were maintained and foods were stored in safe conditions. * There were expired food items stored inside the facility's freezer.* The stock pot was observed with black discoloration, warped and dented.* Two ceiling vents were dusty and corroded. Additionally, the meat products stored under the vents were also dusty with yellow stains/discoloration.* One cook did not wear a beard restraint.* One dietary aide placed his hands in a red bucket containing sanitizing solution and a dish rag instead of performing hand hygiene. These failures posed the risk of foodborne illness to the 68 of 68 residents who received food prepared in the facility's kitchen.Findings: 1. […]

• No harm, potential for more than minimal, patternF880Jan 15, 2021

  Based on observations, staff interviews, and facility policy review, the facility failed to ensure one staff member followed facility protocol for hand hygiene and transmission-based precautions when entering seven of 24 rooms in the facility's yellow zone. This failure had the potential to increase the spread of infection, including COVID-19, to the 54 residents in the facility's yellow zone. Findings include: On 01/14/21 at 11:18 AM, Housekeeper (HK) 2 stated he had received training on COVID-19 policies and procedures and wore a gown and gloves in addition to a face mask and face shield when cleaning in each resident room. On 01/14/21 at 11:31 AM, HK2 entered room [ROOM NUMBER] wearing a face mask and face shield. He was not observed to don gloves or gown. […]